Clinical Education and the Professions

Speech-language=20
pathologists and audiologists have been involved in clinical education =
since the=20
beginning of the profession. Indeed, education seems to have been the =
one=20
component that has affected everyone in the profession at some time =
(ASHA=20
Committee on Supervision in Speech-Language Pathology and Audiology, =
1978a).=20

Clinical education is a component of the professions of =
speech-language=20
pathology and audiology at many levels. It is an aspect of the training =
that=20
every speech language pathologist (SLP) and audiologist has experienced =
during=20
his/her clinical preparation. Other supervisory relationships are less =
commonly=20
encountered, but certainly exist in the professions. These include

The information included here will focus on the supervision of =
graduate=20
student clinicians and clinical fellows and is directed to supervisors =
who may=20
be supervising for the first time or who are interested in additional=20
information that may be of assistance relative to the supervisory =
process.

Students who are working to become SLPs or audiologists must be =
supervised in=20
a variety of settings and have experience with clients/patients across =
the age=20
span presenting with a variety of communication disorders.

Supervision of Graduate Students

For the graduate student and clinical fellow, supervision is a =
process where=20
the learner is guided and supported through his/her clinical training =
with the=20
goal of developing clinical and professional knowledge and skill. =
Graduate=20
student clinicians often obtain their first clinical experiences at an =
on-site=20
university clinic.

General Timeline/Process

Clients/patients are assigned by the program's clinic director and =
generally the patient load for each student is considered to be =
"light"=20
(students may have a caseload of 3-6 patients to begin their clinical=20
training).

Subsequent to the initial experiences in the university setting, =
graduate=20
students are generally placed in off-site full-time placements =
enabling them=20
to further develop clinical skills, experience a more "real-world" =
schedule,=20
obtain clinical experiences in a variety of settings, and obtain the =
remaining=20
diagnostic and intervention hours necessary to meet certification=20
requirements.

Typically, students are assigned to externship placements toward =
the end=20
of their graduate program. Supervisors must be cognizant of the =
limited=20
experience of supervisees and recognize that the student is not ready =
to "hit=20
the ground running" at the initiation of any clinical experience. The=20
supervisee is continuing to learn and is being provided the =
opportunity to=20
apply the theory learned throughout the graduate curriculum to =
clinical=20
practice.

Graduate students should be assigned to practicum experience after =
they=20
have had sufficient coursework to support the knowledge needed to work =
with=20
the clinical population. Only direct contact with patient/client or =
the=20
patient's/client's family in assessment, management, and/or counseling =
can be=20
counted toward practicum.

Clinical Teaching vs. Classroom Teaching

Clinical education/clinical teaching differ from classic classroom =
teaching=20
in a few ways:

Clinical teaching is generally one supervisor with one graduate =
student=20
clinician or one supervisor with a small group of graduate student =
clinicians.=20
Sometimes, the supervisor will be assigned one graduate student extern =
to=20
spend an extended period of time working with the supervisor (a =
semester),=20
sometimes a graduate student will be assigned for part of a day once =
or twice=20
a week.

In a university setting, the supervisor may be assigned to =
supervise=20
several students but will generally spend some time working =
individually with=20
each graduate student extern. This is a different teaching scenario =
than that=20
of the classroom where a professor's goals are centered on a larger =
group of=20
students reaching defined competencies within a specific content =
area.

In the clinical supervision area, graduate student clinicians may =
work=20
with a variety of patients/clients across disorder types/ages. To some =
degree,=20
clinical supervision works on the premise that the supervisee is =
working in a=20
"criterion-referenced" paradigm.

The supervisee works at his/her own pace and works to achieve =
target=20
competencies.

Role of the Educator

A key role of the clinical educator is to develop skills in the =
student that=20
will enable him/her to critically evaluate and use new information =
gained from=20
one sort of diagnostic or treatment experience to another that may pose =
slightly=20
different challenges.

Requirements of the Clinical Educator

Only those professionals who hold the Certificate of Clinical =
Competence=20
in speech-language pathology or audiology are eligible to serve as =
supervisors=20
or clinical educators. Maintaining certification is of critical =
importance to=20
the supervisory role.

In the revision of the standards for certification, it is noted =
that the=20
amount of supervision provided to the supervisee is not specifically =
defined=20
for audiology; however, a minimum percentage of direct real time =
supervision=20
is indicated. (Standard IV-E)

The graduate student should receive supervision based on the =
"student's=20
level of knowledge, experience, and competence. Supervision must be =
sufficient=20
to ensure the welfare of the client/patient."

It is advisable that the supervisor monitor the number of clinical =
hours=20
earned, although it is the student's responsibility to maintain a =
record of=20
the earned hours.

Although ASHA has moved away from specific hour requirements within =
each=20
disorder area, licensure requirements in many states have not changed to =
match=20
requirements for clinical certification. Graduate student clinicians =
need to=20
visit the ASHA Web site and become familiar with the particular state =
requirements that apply.

Orientation to the University Clinic

Ulrich (1995; October) has provided information as to the importance =
of a=20
detailed orientation to the supervisory experience at any given setting. =
Graduate students at the university setting generally have a =
face-to-face=20
orientation with clinical faculty or are provided with a detailed manual =
for the=20
student outlining requirements for the assignment.

Information to be included in the orientation typically includes, but =
may not=20
be limited to, the following:

time requirements for the assignment (days of the week, time =
needed prior=20
to scheduled client/patient responsibilities)

dress code

emergency procedures (what should the graduate student do if ill =
or unable=20
to attend a session)

Establishing and Maintaining an Effective Working Relationship

ASHA's position statement on Clinical Supervision in Speech-Language=20
Pathology and Audiology (1985) highlights 13 tasks and skills of =
supervision=20
considered basic to successful clinical teaching. One of the tasks notes =
the=20
importance of establishing and maintaining an effective working =
relationship=20
with the supervisee. This task is basic to the success of the =
experience.=20
Clinical education is evaluative and the supervisee is in a position of =
reduced=20
power in the relationship.

Clinical educators need to recognize the power differential and be =
sensitive to it. The supervisory relationship is a unique one, and =
because of=20
the fragility of the relationship, it is usually not beneficial to =
exert power=20
when working with the supervisee.

An atmosphere where learning is supported should be provided.

The supervisee should feel comfortable in presenting thoughts and =
ideas=20
relative to clinical challenges.

On the other side of the supervisory relationship, it may not be =
healthy=20
to develop a close "friendship" with the supervisee.

The supervisee needs to understand that the supervisor is a =
teacher and=20
too much social comfort may not provide for a situation where the =
supervisor=20
can evaluate performance independently of the relationship.

A balance where the supervisor and supervisee are "friendly" and =
where the=20
relationship is one of mutual respect and support is optimal.

Open and ongoing communication between the supervisor and the =
supervisee=20
is central to the success of the supervisory relationship.

It is important for clinical educators to meet with each supervisee =
prior to=20
initiating the clinical assignment/experience. This preliminary meeting =
should=20
"set the stage" for the clinical/supervisory experience. Supervisees =
benefit=20
from knowing the expectations of the clinical educator, and the clinical =
educator should, in turn, explore the supervisee's expectations for the=20
experience and for the supervisor. This first meeting should provide the =
participants some sense of what will develop over the time the graduate =
student=20
is assigned to this clinical educator.

Externships

Much like a new job, the arrival at an externship experience is both =
an=20
exciting and stressful experience. By orienting the supervisee to things =
like=20
the introduction to the site will be a smoother process. Some settings =
may be=20
considered to be best suited for a student who can manage a schedule =
that=20
changes hour to hour, or some settings may involve patients that are =
critically=20
ill. It is important to understand the needs of the graduate student, =
the=20
clinical educator, and the requirements of the setting in order to avoid =
potential issues before the student is assigned to a specific facility. =
The=20
university should provide the externship clinical educator with =
information=20
about the number of hours needed at the particular placement site and =
types of=20
experiences required (e.g., specific patient disorders, ages).

For placements that are off-campus, the university will

typically establish a contract, which should outline the =
responsibilities=20
of the university and the clinical site and should serve to protect =
all=20
parties

generally have a coordinator of externships (or similar title) who =
will=20
then follow through in setting up the details of the student's =
experience

establish placements up to a year in advance of the =
assignment

determine start and end dates and review any requirements of the=20
particular setting. For example, a hospital setting might require that =
the=20
student be available to work weekends or that the student have =
completed=20
coursework in the area of dysphagia.

Orientation information to supervisees includes

information as to where to park, requirements for health=20
screenings/examinations, background checks

time schedule for the days in clinical experience (lunch =
break)

information on grading of performance of graduate students and =
information=20
on evaluation process for clinical fellows

billing procedures, dress code, emergency procedures, paperwork=20
requirements, and the policies and procedures that are unique to the =
placement=20

Anderson's Model

With this foundation, the supervisor and supervisee can move to the =
core of=20
what supervision is all about. Anderson (1988) created a model of the=20
supervisory process referred to as the Continuum of Supervision. This =
tool=20
provides a framework from which the supervisor and the supervisee can =
view the=20
process together. The continuum provides a fluid model that supports the =
individual student's growth.

The supervisor serves as "the lead" in planning for the needs of =
the=20
clients with whom the supervisee is working.

The supervisory feedback is considered to be "direct-active" in =
that the=20
supervisor controls and the supervisee follows direction.

The marginal student, the student who evidences difficulty in =
planning,=20
critical thinking, time management, and/or other areas of the therapy =
process=20
may remain in the evaluation-feedback stage for an extended period of=20
time.

Typically, this is a more comfortable start for the supervisee; =
however it is=20
the hope that the student will move through this stage of development =
relatively=20
quickly. Be aware that for many supervisees, the direct-active =
supervisor is the=20
easiest to work with for most, movement on the continuum to the =
transitional=20
stage is anticipated,

2. The transitional stage : Some of the =
responsibility for=20
case and client management shifts to the supervisee.

This process is seamless and allows the supervisee the opportunity =
to=20
begin participating in the planning, implementing, and analyzing the =
course of=20
treatment for patients/clients. The transition to independence can =
create=20
anxiety for the supervisee and the supervisor.

The supervisee is anxious relative to the increased responsibility =
and=20
planning required for the patient/client.

The supervisor may feel anxious relative to "giving up control" =
for the=20
patient and family. In addition to the new clinical student, a =
supervisee who=20
is working with a new clinical population will generally begin in the=20
evaluation-feedback stage. The supervisor needs to be sensitive to any =
signs=20
of unusual stress exhibited by the supervisee.

In this transition stage, the supervisor provides input and =
feedback;=20
however the tone of the supervisory relationship becomes more of a =
joint=20
project between the supervisor and the supervisee.

The supervisee may be able to become more independent when working =
with=20
clients having some disorder types sooner than with other disorder =
types=20
(e.g., the supervisee may work effectively in setting short and long =
term=20
goals with children with phonological disorders but may have =
difficulty=20
establishing reasonable goals for children with autism). The desired =
outcome=20
of the transitional stage is that the supervisee begins to demonstrate =
clinical and professional skills with some degree of =
independence.

It is expected that the supervisee will become more participatory =
in all=20
aspects of client management and will begin to self-analyze clinical =
behavior.=20
It is possible that with certain skills (i.e. session planning) the =
supervisee=20
may require little direction from the supervisor. However, the same =
supervisee=20
may consistently evidence difficulty at communicating at an =
appropriate=20
language level with clients/patients. In this case, the supervisor can =
provide=20
collegial mentoring providing additional ideas or reinforcement as the =
graduate student establishes short term goals for sessions, selects =
materials,=20
etc.

The supervisor may need to be directive in supervisory style when =
working=20
with the same student in "scripting" information to be provided for =
the family=20
emphasizing appropriate vocabulary choices, definition of professional =
terminology, etc.

3. The self-supervision stage : It is the goal for =
each=20
supervisee to move to the self-supervision stage. When the student =
reaches this=20
stage of the continuum, the supervisor serves in a consultative role =
with the=20
supervisee.

The supervisee grows in clinical independence.

The supervisee is better able to plan and implement therapy with =
less=20
direct supervisory input.

The supervisor begins to serve in a more collaborative role and =
feedback=20
at this stage mirrors the change in the supervisory role. The =
supervisor=20
listens and supports the supervisee in problem solving.

The supervisee is responsible for the primary management of the=20
caseload.

Significantly, Anderson notes that the continuum is not time-bound. =
This=20
means that there is no set period of time that a supervisee should =
achieve a=20
particular skill. The continuum is designed to support the supervisee in =
the=20
development and self-recognition of clinical and professional strengths =
as well=20
as the development and self-recognition of those areas requiring =
additional=20
development of skill.

Evaluation of Supervisee

At University Clinic

Other tasks of clinical education address the clinical and =
professional=20
skills required of the SLP or audiologist. Demonstrations by the =
clinical=20
educator may be an effective strategy for clinical teaching; however, be =
aware=20
that the supervisee needs to develop his/her own clinical style. The =
goal of=20
clinical education is not to create a clone of the clinical educator. =
The=20
supervisee requires self-awareness to eventually work independently. =
Some=20
supervisees may not recognize any of their own clinical strengths; =
others may=20
not recognize any of their weaknesses.

Providing Feedback

Feedback is critical to the development of self-awareness and to the=20
development of the clinical and professional skills of the supervisee. =
Ongoing=20
oral and written feedback is recommended.

Be cognizant that a comment in the hallway between patients may =
not be=20
understood, remembered, nor are such comments confidential.

Written feedback provides a lasting record of information provided =
to the=20
supervisee (and to the supervisor).

Provide a balance of things that the supervisee is doing well with =
the=20
areas that the supervisee should target for improvement. A long list =
of things=20
that are not going well will only overwhelm the supervisee in a =
negative=20
way.

At the Externship

Evaluation of the supervisee typically follows a schedule provided by =
the=20
university setting. The clinical educator should receive information =
about the=20
grading process including the evaluation tool. Universities provide =
information=20
as to the contact at the university, and clinical educators should feel =
free to=20
contact the university liaison with questions and problems relative to =
the=20
experience. Many universities will have a scheduled visit to the =
placement to=20
review how the externship is progressing. At that time, any concerns of =
the=20
supervisee and/or the clinical educator should be discussed. It is not =
the=20
off-site clinical instructor's responsibility to manage any difficulties =
with=20
the supervisee independently. The university liaison will provide =
support in=20
problem solving strategies in managing issues or concerns.

Supervision of Clinical Fellows

Clinical education of the clinical fellow differs in that the =
clinical fellow=20
is generally an employee of the site. The clinical fellow will have =
applied for=20
a position with the facility and has typically interviewed for a =
position. There=20
should be a job description outlining the responsibilities of the =
position. An=20
orientation as a new employee of the site should be provided. The =
clinical=20
fellow should meet with the mentor/supervisor at the initiation of the=20
employment. It is not a requirement of the experience that the =
mentor/supervisor=20
be on-site or that the mentor/supervisor be employed at the setting =
where the=20
clinical fellow is employed.

Eighteen other monitoring activities are required. Examples of =
these=20
activities are e-mail communication between the mentor/supervisor and =
the=20
supervisee, phone conferences between the mentor/supervisor and the=20
supervisee, and/or review of written reports.

The term mentor/supervisor is used to acknowledge that the role of =
the=20
supervisor for the clinical fellow is different from that of the =
supervisor of=20
the graduate student clinician. To some extent, the supervisory =
relationship=20
is taken to the next level in the clinical fellowship experience. The=20
mentor/supervisor is a resource, a support, a sounding board for ideas =
or for=20
discussion of particular cases or professional issues.

Professional Ethics

As in all aspects of the professions, ethical behavior must oversee =
all=20
actions associated with the supervisory process. The Code of =
Ethics (ASHA,=20
2010) addresses the supervisory process as noted by:

Principle I - Individuals shall honor their responsibility to hold =
paramount the welfare of persons they serve professionally or who are=20
participants in research and scholarly activities, and shall treat =
animals=20
involved in research in a humane manner.

Principle IV - Individuals shall honor their =
responsibilities to the=20
professions and their relationships with colleagues, students, and =
members=20
of other professions and disciplines.

The Code of Ethics guides clinical educators to continually ensure =
that the=20
patient is optimally served, that supervisees are provided quality =
supervisory=20
input, and that the supervisee is respected throughout the =
experience.